Writer Ignites Firestorm With Misdiagnosis Claims

Psychiatrists and a popular science writer have collided over claims made in a recently published book that revives the controversy about a 30-year-old study questioning the validity of psychiatric diagnoses.

The controversy, which has been brewing for nearly two years since the book was published, has more recently made its way into the scientific literature in a remarkable exchange between the combatants in the Journal of Nervous and Mental Disorders.

Robert Spitzer, M.D., of Columbia University College of Physicians and Surgeons, and other psychiatrists and psychologists have called into question claims made by science writer Lauren Slater in her 2004 book, Opening Skinner's Box: Great Psychological Experiments of the 20th Century.

In that book, Slater describes a journalistic exercise in replicating an experiment made famous by David Rosenhan in 1973 in which he enlisted healthy individuals with no ostensible history of psychiatric diagnosis to pose as patients hearing hallucinatory voices. Rosenhan's account was published in 1973 in Science under the title “On Being Sane in Insane Places.” All of the pseudo-patients were admitted to psychiatric hospitals, and all but one were diagnosed as having schizophrenia; the pseudopatients, who claimed to have stopped hearing the voices after admission, were diagnosed at discharge with schizophrenia in remission.

Hearing the Word `Thud'

In Opening Skinner's Box, Slater recounted the Rosenhan study and his conclusion that psychiatric diagnoses are products of social context rather than objectively verifiable scientific criteria, as well as the enormous impact that the study made on the psychiatric profession and public perception of the reliability of diagnosis.

Slater also reported the results of her own exercise in posing as a patient: At nine separate emergency rooms, Slater said she presented herself as a patient seeking treatment because of a voice she was hearing that was saying the word “thud” (one of the same words Rosenhan's pseudo-patients claimed to hear). She further reported being prescribed 25 antipsychotics and 60 antidepressants and said that she was diagnosed“ almost every time” with psychotic depression.

“It becomes fairly clear to me that medication drives the decisions, and not the other way around,” Slater wrote. “Rosenhan's point that diagnosis does not reside in the person seems to stand.”

Credibility Questioned

Spitzer, whose conversations with Slater are quoted in the book, is skeptical.

“When I read it, it just didn't make sense,” he told Psychiatric News. “Someone presents in the emergency room only hearing the word `thud' and moreover denies being depressed—there's no way that someone is going to say that is psychotic depression. You don't make a diagnosis of psychotic depression on the basis of hearing the word `thud.'”

Spitzer, who was editor of DSM-III and has been an important figure in the evolution and refinement of psychiatric diagnoses, said he requested to see evidence of Slater's experiment—including files from her visits to the ERs or names of psychiatrists or hospitals—but that she has not produced them. And he told Psychiatric News he is highly skeptical about the medications Slater reported she was prescribed.

Spitzer is not alone in his reactions. “It would be nice if she could assuage my concerns about her study by providing us with objective evidence that she did it,” psychologist Scott Lilienfeld, Ph.D., told Psychiatric News. “It would be comforting if she could provide us with files from her visits to the ER, the name of one attending psychiatrist she saw, or the name of hospital she visited. She hasn't done any of that.... I don't know what happened. But I don't think we should take it seriously until she can provide us with documentation.”

Lilienfeld is an associate professor of psychology in the Department of Clinical Psychology at Emory University in Atlanta.

Others are less circumspect. “I believe the data were fabricated,” psychiatrist Mark Zimmerman, M.D., told Psychiatric News. “As a researcher, I know that if anyone has a question about my data, how easy it is to produce data files, and Slater hasn't done that.”

What Slater has done is to offer a response to Spitzer and colleagues in the November 2005 Journal of Nervous and Mental Disorders.

In what must surely be one of the more unusual exchanges to take place in a scientific venue, Slater says what she described in her book is not a“ study” and cannot be critiqued as such.

“The book features not only the experiments and the experimenters, but me, as well, and my husband, and my daughter and my pet raccoon,” she wrote. “In any case, such a colorful cast of characters and deeply personal details.. .are in and of themselves enough to make abundantly obvious to any and all readers that we are not here dealing with an academic inquiry, or `study.' That Spitzer et al. have chosen to label my work as a study is a silly and troubling mischaracterization.... The authors also fully understand that my use of the word `experiment' is of course vernacular, as in, `honey, let's experiment with this recipe tonight.' It would be far more useful, and appropriate, if the authors would drop the bloated and obfuscatory remarks, hunched and hiding as they are behind the veneer of `science,' and claim their point in plain language. Their point, as far as I can see, is that they think I lied, which probably would not bother them so much if my alleged `lie' did not result in narcissistic injury.”

Reached at her home, Slater told Psychiatric News that she had no more comment on the controversy beyond the response she published in the journal. A spokesperson for the book's publisher, W.W. Norton, also declined to comment.

In that same journal, Spitzer, Lilienfeld, and Michael B. Miller, Ph.D., published a study in which they presented 74 emergency room psychiatrists with a case vignette modeled on the description in Slater's book and asked them a series of questions regarding diagnosis and treatment recommendations. In contrast to what Slater reported, just four psychiatrists offered a diagnosis of psychotic depression, and only a third recommended medication (see box).

“Our study raises questions regarding Slater's results and conclusions, and provides scant support for the claim that psychiatric diagnoses are mostly the product of fashion or fad, as claimed by Slater,” they concluded.

They also published a rejoinder to Slater titled “A Response to a Nonresponse to Criticisms of a Nonstudy: One Humorous and One Serious Rejoinder to Slater.” Finally, Zimmerman wrote a review titled“ Pseudopatient or Pseudoscience: A Reviewer's Perspective.”

All of the documents are posted at<http://taxa.epi.umn.edu/~mbmiller/journals/jnmd/Rosenhan>.

Spitzer and others said that the issue is a serious one involving not only the veracity of an acclaimed science writer, but the trust of patients and would-be patients in their doctors.

Spitzer was critical of the original Rosenhan study and published a critique that appeared in the April 1976 Archives of General Psychiatry. But he has acknowledged the profound impact it had on popular perceptions of psychiatry.

Thirty years later, when the field has made enormous strides toward refining diagnostic criteria, Slater's work threatens to undermine patients' faith, he said. “There is a real possibility that there will be patients who read this book and wonder if they can depend on their doctor's diagnosis,” Spitzer said. “She's resurrecting a flawed study that will be used to make fun of psychiatry and affect the public image of the profession.”

Lilienfeld agreed. “This is a popular book and one that may well be read by a lot of people in the general public,” he said. “In this chapter [on Rosenhan] she argues forcefully that psychiatric diagnoses are arbitrary and driven mostly by medication choices. She communicates very strongly the impression that much of psychiatry is pseudo-science. She doesn't use that word, but any reasonable person would come away with the impression that psychiatric diagnosis is much more of an art than a science, and that psychiatric diagnoses are entirely a product of context.

“The book may lead people to take psychiatric diagnoses less seriously,” he said. ▪